NCLEX-PN® ExaminationBasic Care and ComfortMedium
An LPN is teaching a client about preventing pressure injuries. Which instruction is most important for the LPN to emphasize for a client who is bedridden?
- A''Maintain a high-protein diet to promote skin healing.''
- B''Use a donut-shaped cushion when sitting in a chair.''
- C''Keep your skin clean and dry, especially in skin folds.''
- D''Change your position at least every 2 hours.''
Show answer & explanationAnswer & explanation
Correct answer: D. ''Change your position at least every 2 hours.''
For a bedridden client, immobility is the primary risk factor for pressure injury development. Frequent repositioning (at least every 2 hours) is the most critical intervention to relieve pressure on bony prominences and allow for tissue reperfusion, thus preventing injury.
Why the other options are wrong
- A. A high-protein diet is important for skin integrity and healing, but it is not the most important preventive measure for a bedridden client's primary risk of constant pressure.
- B. Donut-shaped cushions are generally discouraged as they can cause increased pressure around the central hole and impede blood flow, potentially leading to pressure injury.
- C. Maintaining clean and dry skin is important for skin integrity and preventing maceration, but it does not address the fundamental issue of sustained pressure from immobility.
Pressure Injury Prevention
Strategies to avoid skin and tissue damage caused by prolonged pressure, shear, and friction.
- Frequent repositioning is key for immobile clients.
- Maintain good nutrition and hydration.
- Keep skin clean, dry, and moisturized.
Memory trick: Turn the body, feed the skin, keep it clean and dry.